Addressing the Pain: Dressing the Discomfort: Managing Radiation Therapy-Induced Dermatitis
Painful skin reactions can be a source of significant distress to a patient undergoing radiation therapy. Although technological developments have reduced the frequency and severity of skin reactions, they continue to cause pain and inconvenience for patients. Severe reactions cause interruptions in the patient's treatment schedule, possibly compromising the effectiveness of radiation treatment. In some cases, patients choose to discontinue treatment because of the discomfort.
In the first week of radiation, a very faint erythema may appear due to capillary dilatation. After 2 to 3 weeks, endothelial swelling and proliferation occurs, causing obstruction. Obstruction also occurs in the arterioles from endothelial disruption and intimal thickening. Cell production in the germinal layer of the epithelium decreases and dry desquamation, or scaling begins. After 3 to 4 weeks of daily radiation, moist desquamation may develop as a result of skin peeling, vascular dilatation, edema and oozing of serum from the denuded areas.1
Pain perception due to skin changes varies widely among patients during radiation therapy. Some will report discomfort with the onset of erythema. Others will not complain of discomfort until moist desquamation occurs. In the authors' clinic, patients are evaluated weekly by their physician and nurse during treatment and daily by the radiation therapists with immediate referral to the clinic as needed. Skin pain is evaluated using the Numeric Pain Rating Scale (NPRS).
Although certain skin care principles are commonly used, physicians and institutions often employ a combination of guidelines and products they feel are most effective for patients. Patients are cautioned against using any skin care products not approved by their physician. Antimicrobials such as hydrogen peroxide, hypochlorite, acetic acid, and povidone iodine are not used because they interfere with new skin cell proliferation.1 Gentle cleansing with mild soap and avoiding friction to the affected area are recommended.2 Various dressings can be used to absorb exudate and prevent friction, although occlusive dressings should not be used. The choice of dressing can be a challenge; using tape on the irradiated skin is discouraged.
A new dressing, Mepilex Transfer (Molnlycke Health Care, Newtown, Pa.), has proven beneficial to the authors' patients' symptom management and quality of life. The dressing - an absorbent foam layer with a silicone coating on the side applied to the patient's skin - is useful on a variety of irradiated sites. It does not adhere to a moist wound area, does not require tape, does not tear skin when removed, and can be lifted and readjusted without losing its adherence. It was primarily designed to transfer exudate from a wound to an absorbent dressing. However, for radiation patients, it also has proven effective in reducing distress from painful skin irritation caused by friction and pressure (see Figure 1).
The dressing is used most frequently on breast cancer patients who report a pleasing cool sensation when it is applied. One patient found clothing so painful that she spent a great deal of time at home with the shades drawn in order to avoid wearing any clothing on her chest. The product brought immediate relief, and clothing was no longer a problem. Breast cancer patients find the infra-mammary fold to be a common area of desquamation and irritation. Applying dressings that remain in place in this location is difficult. The adherent, flexible, conforming nature of this product allows it to stay in place and prevent the skin-on-skin friction that normally occurs in this area, particularly when wearing a bra is no longer comfortable. Some patients find that applying the product to their affected skin at night reduces discomfort from pressure and bed sheets. Other patients have applied it to a small pillow they place under their arm when the axilla is affected.
The dressing also provides relief to patients receiving lower pelvic irradiation. It adheres well to the groin area, preventing clothing and skin friction. Patients who have arrived in clinic with an abnormal gait due to pain in the groin area have left feeling better and walking normally after the product was applied. In a patient being treated for rectal cancer, the dressing worked well on a penis that was in the radiation field and causing discomfort due to skin redness and irritation.
The multifaceted nature of the dressing allows room for creativity. One patient complained of skin irritation behind his ears that made his eyeglasses painful to wear. His nurse solved the problem by trimming and wrapping a piece of the dressing around the earpiece of his glasses. Other patients have enhanced the cooling effect of the dressing by storing it in the refrigerator before applying.
The physical and emotional effects of having cancer are often overwhelming. Patients' quality of life may be limited by pain from their underlying disease, anxiety, loss of ability to perform normal activities, and changes in their physical appearance. The additional burden of unpleasant side effects from their cancer treatment is a concern that healthcare professionals continually seek to alleviate. The goal of radiation therapists is to help patients manage their skin discomfort so they are able to complete an optimal course of treatment. Patients have enthusiastically reported pain relief from this dressing. Both staff and patients find it easy to use and to custom fit for patients' needs. Reducing friction discomfort, sleeping better at night, and wearing normal clothing are essential to quality of life.
The authors wish to express their appreciation to Lori Chandler, RN, and Ginger Koon, RN, for their assistance with photography and patient assessment.
Addressing the Pain is made possible through the support of Molnlycke Health Care, Newtown, Pa.